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Hayes ROADMAP MDaudit Risk-Based Audting - 4 Ways Identify Risk
Hayes ROADMAP MDaudit Risk-Based Audting - 4 Ways Identify Risk
Road Map
Risk-Based Auditing: 4 Ways to Identify Areas of Organizational Risk
Risk-Based Auditing: 4 Ways to Identify Areas of Organizational Risk
A recent survey of over 500 healthcare directors and C-suite Risk-based auditing, on the other hand, targets perceived or known areas of
executives identified heightened regulatory scrutiny, rapid speed of risk and vulnerability. A true risk-based audit targets particular practices and
disruptive technology innovation, and ensuring PHI security as the top codes based on specific concerns. Instead of taking a rigid, provider-by-
provider or area-by-area approach, a risk-based program allows the audit team
industry risks for 2016.1 The continuing growth of regulatory
the flexibility to devote auditing resources to areas or providers that may be
compliance demands in the healthcare industry – and the heightened displaying potential negative issues. Risk-based audits are performed on an
risk that comes with it - is placing an enormous strain on auditing ad-hoc, unscheduled basis and are not tied to any particular provider or
resources in most organizations. Deploying those resources in the most practice. In most cases, they target a cross section of providers, zeroing in
effective way means narrowing audit focus to those areas that pose the on trouble areas regardless of location.
greatest risk.
Many organizations are moving to risk-based auditing to combat the increased In the end, all audits are technically risk-based in that the goal is to review
risks prevalent in the healthcare industry today. With only so much time controls to determine how effectively they are ensuring proper coding and
available for auditing, it’s critical for organizations to target specific areas billing. The key difference with risk-based audits comes down to scope and
of interest and not devote time to areas with little or no significant impact. methodology. And with resources becoming scarcer, it becomes more critical
Moving from an annual risk assessment program to a risk-based audit plan to focus in on areas in the organization that present the highest levels of risk.
can be one of the most impactful moves a healthcare organization can make.
Identifying areas of risk
Risk-based versus traditional auditing The first step in risk-based auditing is to identify where the greatest risks
In a traditional audit program, organizations develop plans for a period of time to the organization lie. Here are four ways to help develop these targets.
that involve scheduled, routine audits. For example, many will conduct audits
of all their providers reviewing a set number of cases over a fixed period of
time. There is some focus on risk involved because based on results, the
organization may audit some providers more frequently. However, the overall
goal is getting through the list so all providers are ultimately audited over a
one or two year period.
1
Leverage Multiple Sources
PEPPER
Reports
Identify High
Annual OIG
Risk Areas
Work Plan
Outliers Audit
Automation
Workflow Identify
Automation
Hotline Risk
Submissions
Areas ??
Provider
Questions
Corrective Payor
Action Requests
2
Target Outliers and Trends
3
Being Proactive Minimizes Your Risks
The key benefit of risk-based audits is that it allows you to stay ahead of third
party entities that are trying put a magnifying glass on your organization.
4
Sources
1
Executive Perspectives on Top Risks for 2016: Key Issues Being Discussed in the Boardroom and C-Suite, survey
from Protiviti and North Carolina State University ERM Initiative
5
Once you’ve established a baseline, the next step
is to make improvements by initiating a corrective
action program that addresses your people, process,
and technology.
People
Focus on training and education so everyone in the
organization understands the depth and impact of
About Hayes and MDaudit
the problem and what their role in solving it should
Hayes Management Consulting is a leading, national
be. Specific actions to take include:
healthcare consulting firm and software developer that
partners with healthcare organizations to streamline
operations, improve revenue and enhance technology • Establish accountability and self-reporting by
to drive success in an evolving healthcare landscape. root cause owner and process owner
• Set a zero to low tolerance for finger pointing
Hayes’ MDaudit™ software automates administrative tasks and excuses
involved in the billing audit process, dramatically improving • Recognize improvement and determine conse-
productivity and helping healthcare organizations reduce quences for unacceptable outcomes
billing compliance risk.
Workflow
To learn how MDaudit can help you streamline your A thorough process review will help highlight re-
auditing and compliance program, call 617-559-0404 or dundancies and time-wasting tasks and will quantify
email mdaudit@hayesmanagement.com.You can also request the outcome or performance expectation for each
a demo at www.hayesmanagement.com/software. task. The most effective way to improve the work-
flow process is to eliminate errors that could result
in a denial
Key points to include: